PUBLIC LAW 108–173—DEC. 8, 2003
117 STAT. 2413
SEC. 938. PRIOR DETERMINATION PROCESS FOR CERTAIN ITEMS AND SERVICES; ADVANCE BENEFICIARY NOTICES.
(a) IN GENERAL.—Section 1869 (42 U.S.C. 1395ff(b)), as amended by section 933(d)(2)(B), is further amended by adding at the end the following new subsection: ‘‘(h) PRIOR DETERMINATION PROCESS FOR CERTAIN ITEMS AND SERVICES.— ‘‘(1) ESTABLISHMENT OF PROCESS.— ‘‘(A) IN GENERAL.—With respect to a medicare administrative contractor that has a contract under section 1874A that provides for making payments under this title with respect to physicians’ services (as defined in section 1848(j)(3)), the Secretary shall establish a prior determination process that meets the requirements of this subsection and that shall be applied by such contractor in the case of eligible requesters. ‘‘(B) ELIGIBLE REQUESTER.—For purposes of this subsection, each of the following shall be an eligible requester: ‘‘(i) A participating physician, but only with respect to physicians’ services to be furnished to an individual who is entitled to benefits under this title and who has consented to the physician making the request under this subsection for those physicians’ services. ‘‘(ii) An individual entitled to benefits under this title, but only with respect to a physicians’ service for which the individual receives, from a physician, an advance beneficiary notice under section 1879(a). ‘‘(2) SECRETARIAL FLEXIBILITY.—The Secretary shall establish by regulation reasonable limits on the physicians’ services for which a prior determination of coverage may be requested under this subsection. In establishing such limits, the Secretary may consider the dollar amount involved with respect to the physicians’ service, administrative costs and burdens, and other relevant factors. ‘‘(3) REQUEST FOR PRIOR DETERMINATION.— ‘‘(A) IN GENERAL.—Subject to paragraph (2), under the process established under this subsection an eligible requester may submit to the contractor a request for a determination, before the furnishing of a physicians’ service, as to whether the physicians’ service is covered under this title consistent with the applicable requirements of section 1862(a)(1)(A) (relating to medical necessity). ‘‘(B) ACCOMPANYING DOCUMENTATION.—The Secretary may require that the request be accompanied by a description of the physicians’ service, supporting documentation relating to the medical necessity for the physicians’ service, and any other appropriate documentation. In the case of a request submitted by an eligible requester who is described in paragraph (1)(B)(ii), the Secretary may require that the request also be accompanied by a copy of the advance beneficiary notice involved. ‘‘(4) RESPONSE TO REQUEST.— ‘‘(A) IN GENERAL.—Under such process, the contractor shall provide the eligible requester with written notice of a determination as to whether— ‘‘(i) the physicians’ service is so covered; ‘‘(ii) the physicians’ service is not so covered; or
VerDate 11-MAY-2000
13:59 Aug 30, 2004
Jkt 019194
PO 00000
Frm 00349
Fmt 6580
Sfmt 6581
Regulations.
Notification.
D:\STATUTES\2003\19194PT3.001
APPS10
PsN: 19194PT3
�
